"Holidays Come, Sundays Come. It is Very Sad to be Alone": Transnational Practices and the Importance of Family for Mexican and Puerto Rican Latinxs Living with HIV in the Continental U.S.

Latinxs continue to be overrepresented in the U.S. HIV epidemic. We examined the transnational practices, family relationships, and realities of life of Mexicans and Puerto Ricans living with HIV in the continental U.S. We conducted qualitative interviews with 44 persons of Mexican and Puerto Rican origin participating in HIV care engagement interventions. Framework Analysis guided our data analysis. Among participants, a strong connection to the family was intertwined with transnational practices: communication, travel to their place of origin to maintain family ties, and material and/or emotional support. Separation from their family contributed to social isolation. Many participants lacked emotional support regarding living with HIV. Transnational practices and family relationships were intrinsic to the experiences of Mexicans and Puerto Ricans living with HIV in the continental U.S.; and may help understand the points of reference, health-seeking behaviors, and support sources that influence their health, well-being and engagement in HIV care.

Background

Latinxs (a gender-neutral term to describe people of Latin American descent) continue to be overrepresented in the U.S. HIV epidemic, specifically, men who have sex with men, transgender women, and those with a substance use disorder [1]. Among Latinxs living with HIV in the U.S., 42% are estimated to have been born outside the U.S.[2]. To better address the disparities in HIV outcomes among U.S.- and foreign-born Latinxs, evidence is needed to understand how individual and structural issues drive the high rates of late HIV diagnosis, and sub-optimal access, linkage and retention in HIV care [3, 4].

Historical, political, and economic factors have shaped the processes of immigration from Latin America to the U.S.[5]. Current immigration patterns tend to be unidirectional, with immigrants from Latin America seeking better economic conditions, and providing a critical source of skilled and unskilled labor force in the continental U.S. However, reasons for migrating to the U.S. from Latin America may also include seeking a perceived freer sexual and gender expression and/or more accessible or higher quality health services [6].

In this paper, our goal is to characterize participants in eight HIV care engagement interventions funded through the Health Resources and Services Administration (HRSA) Special Projects of National Significance (SPNS). The interventions were developed and implemented by demonstration sites as part of the Latinx Access to Care Initiative for Mexicans and Puerto Ricans living with HIV in the continental US. We also examine the transnational practices, family relationships, and support sources that may influence their well-being. We define first-generation Mexicans and Puerto Ricans as those who were born and raised in Mexico or Puerto Rico, but migrated to the continental U.S. We define second and third-generation Mexicans and Puerto Ricans as those born in the continental U.S. to one or more parents or grandparents from Puerto Rico or Mexico. The HRSA/SPNS initiative, the interventions, and the transnational framework used to inform the interventions are not the focus of this study, but can be found elsewhere [7, 8].

Conceptual Framework

Transnationalism and the cultural construct of familismo inform our analytic framework, and are two overlapping and intersecting theoretical concepts reflected in the lived experiences of participants in the HRSA/SPNS initiative. Transnationalism refers to the social processes, spaces, cross-border activities, practices and relationships that connect immigrants to their places of origin, while living in their places of settlement [9-11]. We examined transnational practices through participants’ travel to their place of origin; communication with their families in Mexico, Puerto Rico or the U.S.; economic remittances to/from families; and the practices and relationships in their place of settlement that may maintain or recreate a connection to their place of origin.

We examined participants’ family relationships considering the construct of familismo. Rooted in characteristics of societies that may prioritize collective and family needs over individual and personal aspirations, familismo has been used to explain the significance of family in different cultures, including those of Mediterranean Europe and Latin America. Researchers and health providers consider familismo an overarching cultural value that may help explain the strong orientation, commitment, and obligation towards the family among Latin American populations in the U.S.[12].

Methods

We analyzed data from in-depth qualitative interviews with a purposeful sample of participants in the eight HRSA/SPNS sites conducting interventions that included navigation services to link or reengage persons of Mexican and Puerto Rican origin into HIV care. The unique interventions at those eight sites included one-on-one navigation services and health education sessions [7, 8]. This study was part of a multi-site mixed methods evaluation of the interventions.

All interviews were conducted between October 2015 and July 2016, after each of the demonstration sites, located in seven urban areas in six different U.S. states, had implemented their interventions for a minimum of 6 months. The ninth site was not included in the qualitative evaluation because its intervention was different from the other sites and focused on training medical providers on delivering culturally appropriate services in a correctional facility. The study was approved by the Institutional Review Board (IRB) at the University of California San Francisco (UCSF), and reviewed and/or approved by demonstration site IRBs.

Sampling and Data Collection

Our sample included a maximum of six intervention participants at each demonstration site. We asked site staff to select a diverse sample of their intervention participants to interview. Diversity was determined by age (older, younger), new HIV diagnosis or previously out of HIV care, and different levels of engagement in the interventions, as well as gender and sexual orientation according to each site eligibility criteria. The first and second authors, who are bilingual, conducted interviews at seven of the nine demonstration sites. The eighth site shared with us the transcripts of the interviews with their participants conducted as part of its internal evaluation, after harmonizing their interview questions with our research questions and interview guide. Interviews were conducted using a semi-structured guide tailored to the specifics of each intervention that focused on the participants’ background, transnational practices, living with HIV, and intervention services (Table 1 includes the main domains of the interview guide). All interviews were conducted in person in English or Spanish depending on the participants’ preference. No identifying information was collected from participants, who provided written consent before the interview, and received a $40 gift card for their participation. Interviews lasted a maximum 90 min, and were audio-recorded and transcribed verbatim.

Table 1

Interview guide. Latinx Access to Care Initiative for Mexicans and Puerto Ricans living with HIV in the continental U.S

Section 1: Introductory questions	History of engagement with clinic or agency
Section 2: Background	Experiences growing up Time in the continental U.S. Family, social support and romantic relationships Living, work and financial situation
Section 3: Transnationalism and cultural influences	Travel Communication Remittances Life in the continental U.S.
Section 4: Working with navigators implementing the interventions	Services received Relationship with navigators Intervention impact
Section 5: HIV care	HIV care engagement Services needed and received Health in general and co-morbidities Treatment adherence HIV viral load
Section 6: Living with HIV	HIV diagnosis HIV disclosure Perceptions related to living with HIV and being in HIV care
Section 7: Health seeking behaviors	Past and present health seeking behaviors whether in Mexico, PR or the continental U.S.

Areas to explore during the interviews: (1) Experiences participating in culturally competent interventions to link and engage HIV+ persons who self-identify as of Mexican or Puerto Rican origin in HIV care. (2) Transnational influences, health seeking experiences and access to HIV care in the context of being of Mexican or Puerto Rican origin and living in the continental U.S (cultural beliefs, behaviors and structural barriers). (3) Self-identity (ethnicity, gender, sexual orientation, minority status, level of acculturation)

Questions tailored according to: (a) Intervention services provided at each of the participating sites. (b) First, second or third generation immigrants of Mexican or PR origin. (c) Newly diagnosed with HIV or previously out of HIV care

Analysis

Our iterative analytic process was guided by Framework Analysis [13]. This method consists of data immersion, identification of a thematic framework for classifying data, assigning and indexing sections of text to established thematic codes, identifying key themes, and data meaning and interpretation. The first two authors, who conducted most interviews, analyzed the data in the original language of the interview (Spanish or English). Together, they first read and discussed a subset of the transcripts and developed a preliminary codebook, which included deductive and inductive codes based on the interview questions and on themes emerging from the data. Second, they independently coded two transcripts and then compared and discussed the coding and resolved discrepancies. Based on those discussions, they finalized a codebook that was applied to all transcripts entered onto Dedoose, a web application for organizing and analyzing qualitative data [14]. Third, they independently coded each transcript and verified each other’s work for coding consistency. Then, they summarized findings from each interview, examining key themes, mapping thematic relationships, and comparing findings between Mexican and Puerto Rican participants. Here we report on convergent themes that apply to Mexican and Puerto Rican participants across interventions.

Results

We interviewed 44 participants who were mainly first generation Puerto Rican and Mexican men and women living with HIV, aged 21–61 (median age 40 years old) (Table 2). Reflecting the interventions’ eligibility criteria, more than 75% of the participants were Mexican, and most of the men identified as gay. Thirty-four participants were first-generation immigrants and had lived in the continental U.S. from less than a year to 35 years.

Table 2

Demographic characteristics of participants

Characteristics	Puerto Rican	Mexican
Gender (N = 44)
Cis men	10	30
Cis women		1
Transgender women		3
Total	10 (7 second or third generation raised in the continental U.S.)	34 (4 second or third generation raised in the U.S.)
Sexual orientation (N = 44)
Gay	5	27
Heterosexual	4	7
Bisexual	1
Total	10	34
Substance use history (N = 12)
Gay		5 (3 methamphetamine, 2 other)
Heterosexual male	4 (heroin, crack)	1 (alcohol)
Bisexual male	1 (unspecified)
Heterosexual trans female		1 (alcohol)
Total	5	7

We examined the reasons first-generation Mexicans and Puerto Ricans moved to the continental U.S., as well as the transnational practices (i.e., communication with family, travel, and economic remittances to/from families) that intertwined with the importance of family ties among all participants. Living with HIV underlay the participants’ narratives as a significant factor in their lives. For clarity, we refer to Puerto Rico as P.R. or “the island”, reflecting the accounts of Puerto Rican participants who referred to it as their country. The continental U.S.A. is referred to as the U.S. We present findings in alignment with the transnational framework that guided our analysis. The names of participants mentioned in the text refer to the representative quotes in Table 3.

Table 3

Representative quotes related to transnational practices and familismo

Participant	Quotes
Martín (quoted in the title of this paper), straight-identified Mexican man, age 49, city A, 20 years in the U.S., diagnosed with HIV for three years, stated the need to be strong, and that being alone is very sad, but that he chose to be in the U.S., committed to help his family. Sending remittances to his family helped to justify the economic sacrifices and loneliness that he experienced living in the U.S. He had gone back to Mexico a few times, but doubted he could go again, feeling too old and afflicted by another disease to travel back to the U.S., also referring to experiencing hunger, trapped in the dark, making no noise in a crowded truck with other immigrants, walking all night to cross the border, snakes and all	“Vienen las fiestas, vienen los domingos, vienen las navidades. Es muy triste estar solo. Te haces relacionar de más gente (aquí) a manera de no sentirte tan vacío, tan solo. Es difícil, es un sacrificio que yo opté para que mi familia esté un poquito mejor, porque todavía tengo que mandar (dinero) para ellos. Esa es la realidad de una persona que vive aquí. Y mientras yo tenga vida y salud yo tengo que ayudar. Ese es mi compromiso” [Holidays come, Sundays come. Christmas comes. It is very sad to be alone. You relate to people (here) as a way of not feeling so empty, so alone. It is difficult, it is a sacrifice that I chose for my family to be a little better, because I still have to send (money) to them. That is the reality of a person who lives here. As long as I have my life and my health, I need to help. That is my commitment.]
Pedro, straight-identified Puerto Rican man, age 48, city B, 4 years in the U.S., diagnosed with HIV for 21 years, compared a more individualistic way of life in the U.S. with more collectivistic and reciprocal attitudes in P.R. Acknowledging the need for his family and an implicit sense of loneliness, he stated his motivation to be in the U.S. to have access to a service environment he perceived to be better than in P.R	“En la isla somos muy diferentes, pero aquí cada cual tiene que hacer lo suyo. En Puerto Rico tú llegas y todo mundo te da un plato de arroz. Aquí si no tienes familia o no conoces a nadie, nadie te da nada. Aquí tiene uno que chavarse [buscársela]. En parte me gustaría estar en P.R. porque allá tengo a mi familia, a mis hijos, y a mi madre. Y me hacen falta, pero aquí yo tengo más ayuda [servicios] y se me hacen las cosas más fáciles que allá” [In the island we’re very different, but here each to their own. In P.R. when you arrive everyone will give you a plate of rice. Here if you don’t have family or you don’t know anybody, no one will give you anything. You have to fend on your own. Partly I would like to be in PR because I have my family there, my children, and my mother. And I need them, but here I have more help (services), and things for me are easier than there.]
Marta, Mexican transwoman, age 36, city C, in the U.S. for 15 years, diagnosed with HIV for a year, referred to her wish to change her immigration status in the U.S. so she could go to Mexico to see her parents, but not to live, because of the perception that HIV treatment may not be the same there. She also referred to the relationship and connection between her and her parents, who were the motivation for her to keep living. Her parents supported her transition from male to female, but she had not disclosed her HIV status to them	“Hay momentos en que yo quisiera ser legal y poder ir a México, porque aunque sé que en México puedo conseguir los medicamentos, muchos dicen que no es la misma medicina que nos dan aquí. A mí no me importa morirme [si volviera a México y no tuviera medicamentos para el VIH]. Lo que me da miedo es dejar desamparados a mis papás. Yo no quisiera morirme por ellos. Mis papás son mi motor por el que yo estoy aquí” [There are times when I would like to have papers and be able to go to Mexico, because even if I know that I can get medicines in Mexico, some say it is not the same medicine they give us here. I don’t mind dying (if she went back to Mexico and did not have HIV medicines). What I am afraid of is to leave my parents unprotected. I would not like to die because of them. My parents are my engine to be here.]
Jorge, Mexican gay man, age 46, city D, in the U.S. for 19 years, newly diagnosed with HIV, echoing the sentiment of other Mexican participants, stated that he would accept having to go back if deported, but that having spent half of his life in the U.S. he wanted to stay, grateful for what the U.S. had given him	“Me gustaría volver pero de vacaciones, no para quedarme. Yo le pido a Dios no [ser deportado]. Ya dejo la mitad de mi vida aquí, este país me ha dado mucho.” [I would like to go back on vacation, but not to stay. I ask God not to (be deported). I have spent half of my life here, this country has given me a lot.]
Alonso: Mexican gay man, age 36, city E, in the U.S. for 17 years, diagnosed with HIV for 15 years, suffered childhood abuse in Mexico by his brothers and father, and was raped in the U.S. at 19, while working in the fields. Something that helps him go forward is the hope to be able to see his mother again	“Yo fui amenazado, fui golpeado, fui humillado por mis hermanos, por mi papá. Mi mamá, bendita, ella nunca me hizo a un lado. Cuando yo llego a este país… un niño de 19 años trabajando en el campo, donde era explotado, donde fui violado también. He salido adelante porque tengo la ilusión de poder nuevamente ver a mi mamá, abrazarla.” [I was threatened, beaten, humiliated by my brothers, by my father. My mother, bless her, she never push me aside. When I arrived in this country… a 19 year old kid working in the fields, where I was exploited, where I was raped also. I have gone forward because of the hope of seeing my mother again, hug her.]
Daniel: Second generation Puerto Rican gay man, age 22, city F, newly diagnosed with HIV, regularly sent economic remittances to his mother, who lived in a different U.S. State. While emphasizing that he was close to and loved his mother, he resented the financial responsibility that his brother and father did not assume	“I have to send her money. I don't mind doing that, but there’s so many times where I’ve had to help her. Of course I’m her son and I love her immensely, but I feel like I’m more of a provider. I had to start doing that when I was like 18 or 19. Just because my brother’s the hood rat of the family, and then my dad’s who’s a jerk”

The participants’ quotes, using fictitious names, and explanatory comments may apply to one or more sections of the text. We have assigned letters from A to F to the six different cities where the participants we quote participated in the HRSA/SPNS interventions. If the interview was conducted in Spanish, we include the original quote in Spanish with its English translation

Seeking a Better Life. Migrating to the U.S.

Most first-generation Mexicans and Puerto Ricans had migrated to the U.S. as adults for different reasons, which were not mutually exclusive. For many, their explicit motivation to migrate was to seek better economic conditions for themselves and their families. Some of the gay men and transgender women had migrated away from families or physical environments, such as small towns or rural areas that they felt inhibited their sexual or gender expression. A few of the gay men and the three transgender women stated that they had been deeply affected by emotional, physical and sexual abuse and bullying by relatives, friends, or neighbors as children or young adults in Mexico. Despite leaving Mexico in search of a safer environment, two of the gay men and one of the transgender women also reported that they had been sexually assaulted in the U.S. A few participants diagnosed with HIV in Mexico or P.R. had migrated because they perceived that HIV care and treatment were better in the U.S. A couple of Puerto Ricans, encouraged by their families, had left P.R. because of trouble with the law or to enter drug rehabilitation in the U.S.

Family Ties

Family relationships emerged as central in most participants’ lives, partly defining their personal and ethnic identity and connection with their place of origin. Many participants had family members still living in Mexico or P.R., and/or had family in different areas of the U.S. The importance of family ties was expressed in the commitment, responsibility, and obligation implicit in the relationships between participants and their families. Siblings, children, but most often the mother, as in Alonso’s case, were significant family figures providing an emotional anchor in their lives.

Family in Mexico, P.R. and/or in the U.S. played an important role in the migration history of first-generation Mexicans and Puerto Ricans. Their decision to migrate to specific locations in the U.S. frequently had to do with family connections that could provide material support, offer a place to live, or facilitate finding work when first arriving in the U.S. A few participants, however, stated that they felt mistreated or financially abused by the receiving families after their initial welcome or sense of commitment had worn out. A Mexican gay man explained that he had to move out from living with extended family after his relatives realized that he was “different” in his sexual orientation.

Life in the U.S.

Few first-generation Mexicans and Puerto Ricans had achieved the economic success that motivated them to migrate initially. Many struggled to support themselves, let alone send economic remittances to relatives. While many participants were employed, often with multiple jobs, most would be considered low-income. Nevertheless, some participants, such as Jorge, expressed gratitude for their living conditions in the U.S. Some Mexican participants not authorized to work in the U.S. held temporary or seasonal jobs (e.g., hospitality or construction jobs). Overall, second and third- generation participants held more stable jobs and were more secure economically. Participants of Mexican origin who could work legally in the U.S., and had greater fluency in English, had better job opportunities and economic stability. A few participants did not have stable housing, were living in temporary shelters, or with friends or relatives.

Many first-generation Mexicans and Puerto Ricans were monolingual Spanish-speaking. They lived in Latinx neighborhoods where they could feel safe in a familiar environment, communicate in Spanish, and recreate aspects of their lives similar to their place of origin. In these neighborhoods they could access venues and institutions, such as stores, restaurants, bars, or churches that mirrored cultural and social aspects of their life in Mexico or P.R. Second and third-generation Mexicans and Puerto Ricans had grown up speaking English, with different levels of proficiency in Spanish, but as part of families in which parents or grandparents only spoke Spanish and maintained Latinx cultural practices. A few of the second-generation participants had grown up translating for their monolingual Spanish-speaking parents as a way to help them navigate life in the U.S. These patterns were similar for both Puerto Ricans and Mexicans in our sample.

Communication with Families

While participants’ connection to their family varied, it manifested through communication with relatives to maintain or renew family ties. Most first-generation Mexicans and Puerto Ricans were in regular communication by phone, text, and free video or text messaging applications (e.g., Skype, WhatsApp) with their nuclear or extended families in Mexico, P.R., and/or other areas in the U.S. The significance and frequency of that communication and the degree of emotional support it provided depended on the particular relationship between the participants and their families. In some cases, personal conflict or financial disagreements with parents, siblings, spouses, or other relatives punctuated communication. Long distance communication could be fragmented and masked difficult realities, with participants hiding their economic struggles, social isolation, and HIV status from their families. Communication and frequency of travel to their place of origin changed over time as participants’ circumstances and relationships with their families evolved.

Travel Back Home

Participants talked about their wish to visit their place of origin, but their life circumstances limited their ability to actualize that wish. Some first-generation Mexicans and Puerto Ricans who had not seen their families in a long time, expressed a desire to see their elderly parents, especially their mother, before they died. Despite this, travelling remained difficult for different reasons including cost, potential job loss, and, for undocumented Mexicans such as Marta, the risk of not being able to re-enter the U.S. Most participants, like Pedro, did not express a strong desire to move back to their place of origin. Reasons for this included having lived in the U.S. for a long time, a perception that economic conditions and services in the U.S. were better, greater freedom to express their sexuality or gender, and anticipation that they would not be able to find employment back home.

All Puerto Ricans, as U.S. citizens, are not undocumented; therefore they are free to travel back and forth between P.R. and the rest of the U.S. However, among those Puerto Ricans in our sample with a substance use disorder, being on probation and/or estranged from their families because of their substance use or history of incarceration, also precluded traveling back to the island. A few second and third-generation gay men had regularly visited extended family in P.R. since childhood, while others started going to P.R. as adults. One participant described this journey as culture shock, another one discovered that he looked like everyone else on the island and felt a sense of belonging.

Economic Remittances

The regularity of participants sending remittances to their families in Mexico was based on their economic standing. They explained that sending remittances required organizing their expenses, and was part of their priorities and commitment to their families. Remittances helped support families, supplement other income, or pay for additional expenses, such as medication and funerals. For some, sending remittances home helped to justify the sacrifices and loneliness that they experienced in the U.S. Economic remittances occurred in the context of family dynamics, thus, they were not exempt from interpersonal conflict with family members.

Only a couple of the Puerto Rican gay participants sent money to their families. None of the Puerto Rican men with substance use disorders sent remittances, but a couple of them received financial help from their families. A few gay men, such as Daniel, expressed some ambivalence about the financial responsibility to send remittances, perhaps implicitly or explicitly assigned to them by their families, who perceived them to have fewer expenses than straight siblings with financial commitment to their wives and children.

Social Isolation

For many first-generation Mexicans and Puerto Ricans, such as Martín, whom we quote in the title of this paper, physical separation from family had caused psychological distress, sadness, and feelings of social isolation. They described working hard, but also confronting deep loneliness. Participants described the stress of being undocumented and not having enough money to send their families. They frequently used terms in Spanish, such as “aguantar, sacrificarse, resignarse” (to endure, resign, sacrifice oneself) to describe being alone in the U.S. For some participants, social isolation was imbued by a sense of nostalgia for their families and their place of origin. Independent of duration in the U.S., living with HIV and/or substance use disorder also contributed to a sense of social isolation. However, participants’ use of the term aguantar—with its nuanced connotations of resisting or coping—coexisted with a sense of resiliency and their expressed desire to progress. They also described their hope to “salir adelante” (move forward, succeed) with their lives, which also meant actively engaging in HIV care to stay healthy.

As a strategy to build a new life away from their families of origin, cope with loneliness, seek social support, or find a sense of community, some first-generation Mexicans and Puerto Ricans socialized or created families of choice, mainly with other Latinxs. Some gay men socialized with other gay men, sometimes in “antros” (dives), as they referred to the gay Latino bars they frequented. However, these participants’ perceptions of the gay communities and other gay Latinos were mixed. This was evidenced by statements such as, “we are family,” but also by the belief that Latino gay men are all “chismosas” (gossipy) who do not provide mutual support but attack each other. The three transgender women also expressed concern about gossip in the Latinx transgender communities and public disclosure of their HIV status. In terms of specific civic engagement with community work, about a fourth of the participants reported any involvement volunteering at AIDS-related agencies, other community organizations, or at churches. Some of the gay men, regardless of their time in the U.S., reported being in a romantic relationship, mostly with other Latinos. Only one of the straight men and none of the women (either cis or transgender) stated that they were in a romantic relationship (Table 3).

Living with HIV

At the time of the interviews, 21 participants were recently diagnosed with HIV, and 23 previously had been out of care. Some had received a late diagnosis when hospitalized with advanced HIV. Participants’ reasons for having been out of care included a history of substance use disorder, mental health issues, low HIV literacy, lack of knowledge about available resources, HIV stigma, and, if undocumented, avoidance of seeking services because of a perceived risk of deportation. Most participants reported that they had contracted and/or had been diagnosed with HIV in the U.S., statements that did not contradict the timeline and narrative of their history of migration to the U.S.

Twenty-five participants, regardless of their time living with HIV, had not disclosed their HIV status to any family members. Reasons for non-disclosure included concerns related to HIV stigma, fear of rejection, and/or to avoid worrying their families. Some participants who had disclosed their status to family found support from their parents or siblings, who would inquire about their health and encourage them to remain engaged in care. Participants who were alone in the U.S., or had not disclosed their HIV status to their families or to anyone else in their lives, sought and found emotional support through the navigation services provided as part of the HRSA/SPNS interventions. The navigators implementing these interventions applied a transnational approach to explore the transnational practices and the context of their clients’ lives, developed a trusting relationship with them, and helped them identify the strengths and resilience in their lives to engage in HIV care [15].

Most first-generation Mexicans and Puerto Ricans perceived that HIV care and treatment in their place of origin would not be as good quality, would be less accessible, and staffed by providers less dedicated and knowledgeable than in the U.S. While only a couple of participants had direct experience with HIV care in either Mexico or P.R, this perception was derived from the experiences of friends living with HIV, their families’ experiences with health care in general, or their memories and past experiences with health services.

Discussion

We place our findings at the intersection of migration and Latinx studies, transnationalism, and public health efforts to improve HIV care engagement. In line with the goals of the HRSA/SPNS interventions, our contribution to the literature consists of examining the experiences of Mexicans and Puerto Ricans living with HIV in the U.S. to better understand the specificity and the layers of fluid transnational practices and family relationships as points of reference and support sources [16] that influence their well-being and engagement in HIV care.

Overall, transnational practices were similar in the lives of our Mexican and Puerto Rican participants and closely intertwined with the importance of their family ties and relationships. Nevertheless, a fundamental difference exists in our participant sample, as Puerto Ricans are U.S. citizens and many Mexican participants were undocumented. Structural factors and their immigration status in the U.S. made many first-generation Mexicans wary of traveling back to Mexico, afraid of not being able to re-enter the U.S. Most Puerto Rican participants, on the other hand, did not send back remittances to their families. This could be partly due to the different characteristics of our Puerto Rican and Mexican participants. One of the two interventions working with Puerto Ricans focused on people with current or former substance use disorder with few resources. The second intervention focused on Puerto Rican gay men whose nuclear family did not live in P.R.

Participants described relationships and commitment to their families that carried attitudinal and behavioral aspects of familismo, together with protective or harmful factors related to the reciprocity, cost, and benefit implicit in their family relationships [17]. These factors related to a sense of personal sacrifice for the well-being of family members and/or the preservation of family ties. Economic remittances formed part of the context of family dynamics [18]. Even if their family ties were significant and being away from their families caused loneliness and contributed to social isolation, most first-generation participants did not wish to move back to Mexico or P.R. because they had lived in the U.S. for a long time, perceived that their economic conditions in the U.S. were better, and/or felt greater freedom to express their sexuality or gender. Some also justified their will to live in the U.S. and away from their families so they could stay engaged in HIV care. Nevertheless, a sense of longing permeated the narratives of our participants in relation to their families and their places of origin. Thus, familismo may need to be interpreted as an evocative concept, or in a context of nostalgia for ideal circumstances and family relationships left behind [19].

Our findings characterize a population that accessed HIV care in the face of social, political and economic marginalization that may have created barriers to learning their HIV status, linking, and/or reengaging in care. We associate our findings regarding social isolation in the lives of some of our participants with the negative emotional states that may result from structural vulnerability, the concern or stress related to fear of deportation for Mexicans, separation from families, and/or substance use disorder [20, 21]. As a counterpoint, and similar to other findings among immigrant Latino MSM [22], our participants expressed a sense of resilience and a will to “salir adelante” (move forward, succeed) in search of a better life in the U.S.

Ending the HIV epidemic in the U.S. must include improving HIV outcomes among all Latinxs living with HIV. Of note, and similar to findings about HIV transmission dynamics among foreign-born Latinxs [23], most participants reported that they had acquired HIV in the U.S., rather than migrating while living with HIV. The HRSA/SPNS interventions leveraged participants’ resilience, and helped to empower them to overcome barriers to connect and persist in HIV care. Applying a transnational approach was important for the navigators implementing these interventions to explore participants’ histories, strengths and motivations to engage in care, and help them feel that they were not alone living with HIV [15]. In doing so, these interventions could play a critical role in helping achieve national prevention and treatment goals to end the HIV epidemic [24], as they help improve HIV outcomes among low income, uninsured and underserved populations that shoulder multiple and intersectional barriers to care.

Given our qualitative methods, these findings may not be generalized to the experiences of all Mexican and Puerto Rican participants in the HRSA/SPNS initiative or the diversity of all Latinxs living with HIV in the U.S. Further, we cannot draw conclusions from the evidence gathered through our qualitative evaluation that the participants’ transnational practices or family relationships had a direct influence on their engagement in care. Nonetheless, our findings provide a unique view into the transnational practices and family relationships part of the context of their lives that may have affected their mental and physical health and well-being. As such, these findings may have implications for other immigrant populations living with HIV.

In future research, transnational practices and family ties in the lives of Latinxs in the U.S. need to be considered as dynamic and fluid factors changing over time according to personal and structural circumstances [17, 25, 26]. For instance: Mexicans living undocumented are directly affected by U.S. immigration laws [27], and those living with HIV face challenges in their continuity of HIV care when deported back to Mexico [28]. On the other hand, Puerto Ricans arriving with a one-way air fare paid by their families and seeking drug rehabilitation services in the U.S. may continue to struggle with chemical dependence, especially when those recovery services advertised in P.R. prove to be a scam [29]. Latinxs with multiple identities represent the Latinx subpopulations most affected by HIV in the U.S. Because of that, the social identities of first, second or third-generation Latinxs living with HIV need to be analyzed in conjunction with the intersectionality of their sexual orientation and gender [30], or as someone with a substance use disorder [31]. Moreover, the transnational practices of the post-immigration generations merit a separate analysis [32].